DDX
by tobia
Summary: House's assessment at Mayfield, as told by House's psychologist. The tables are turned. Hints of H/W friendship. No slash.


**DDX**

**Disclaimer: I don't own House.**

Jasmine is only a month into her pre-doctoral internship at Mayfield, and she already kind of hates it. She shouldn't, she knows, because she matched into her number one choice, arguably the best site for psychotic disorders in the country—and if any clinical psych grad student knows psychotic disorders, it's Jasmine. By the time she applied to grad school, she had three first author, 2 second author, and one third author publication on the diagnosis and clinical differentiation of schizophrenia-spectrum disorders and twelve national and region poster presentations on psychotic disorders (6 of them as first author). When she was applying to internship last November, she counted a total of eleven publications (7 as first author) on the treatment and diagnosis of schizophrenia and related disorders and over 20 poster presentations on the topic. She's won departmental, NIMH, and APA research grants for her research on the topic, her advisor is one of the biggest, if not simply the biggest, names in the subfield, and even her undergraduate thesis—on the clinical biases exhibited by clinicians in the diagnosis of schizophrenia-spectrum disorders, as mediated by primary training model and continuing education—had been funded and published. Even her clinical work has been highly focused on psychosis—out of the 3,000 clinical hours Jasmine had reported during the internship process, 2,500 had been working with client populations that were either primarily or entirely made up of individuals with some type of psychosis. Yes, if anyone knows psychotic disorders, it would be Jasmine.

Jasmine still hasn't defended her dissertation—a study looking at the effects of mindfulness-based meditation on the reduction of psychosis-induced stress. The uncompleted dissertation had been the only potential red flag on her internship application, one Jasmine imagines many sites had been willing to look past due to her extensive curriculum vita (CV for short—academia-speak for "resume" and a word that Jasmine, even after almost 10 years in the academic grind, still isn't quit sure how to pronounce), one she has been told looks more like a tenured faculty member's than that of a mere graduate student. She's told herself and everyone else that the delay was that so she could recruit participants at Mayfield and get some diversity in her participant pools, but the truth is that part of Jasmine simply doesn't want to do it. Part of her is tired of schizophrenia, of the general poor prognoses, of the horrible side effects caused by meds that sometimes fail to do any good at all, of the fact that she can count on half of one hand the number of times she's ever been told "thank you" by a client. That's not to say there hasn't been good outcomes—there has, and that's what Jasmine often finds herself clinging to—but at times, they've seemed hopelessly few and far-between. Jasmine wishes she had gotten more experience with the "worried well" or at least in subfields where there was a better chance at a good outcome—treating OCD or phobias, depressed college kids, assessing for ADHD—something, anything really, other than psychosis. Things that are still clinical, important, serious, but maybe just a tad less dark, a tad less despairing, But grad school is all about focus and Jasmine is certainly focused.

She got into schizophrenia and psychosis research because that is what her intro to psych professor happened to research, because she thought he seemed funny and nice, because she knew she needed a lot of research to have a shot at getting into a clinical psych PhD program, and because he happened to have an open spot in his lab. She turned out to be exceptionally skilled at research and rose quickly to a spot of prominence in the lab, getting her name on a poster by the end of her freshman year and a publication by the middle of sophomore year. She did an undergraduate internship at a center for people with severe persistent mental illness because that was where her professor had connections, and when she applied to grad school, she applied to work with professors who were researching psychosis and schizophrenia because anything else would have raised eyebrows and because part of her does legitimately enjoy the work.

She applied to ten programs, got into five, and much to everyone's surprise, chose to attend the balanced clinical program at South Dakota, turning down some of the most competitive programs in the field. She guess that everyone thought it was some great coup for the program—to snag both a top-ranked professor and the sort of promising grad student he would attract; the truth is, Jasmine wanted to go a balanced program more than she did a research-heavy one. She wanted the freedom to practice as well as publish, as she knew from before day one that she wouldn't have any freedom at all in her research life. Sometimes, she wonders if she's actually had any freedom in her clinical life, either.

Jasmine picks up the file and begins to read. There's always some controversy about reading a client's file before an initial assessment, but here at Mayfield it's common practice, if just because Mayfield patients frequently come in such a severely decompensated state that assessment is difficult and the medical rule-outs are many. Gregory House, Jasmine soon realizes is no exception to the last rule—the medical history is the most extensive she's ever seen for a patient. Infraction and resulting chronic pain and mobility disability. Vicodin addiction (including an unsuccessful stint at rehab). Severe gunshot wound. Ketamine treatment. Electrocution (self-inflicted—Jasmine reminds herself to carefully screen for suiciduility). Head trauma from a bus accident. Deep brain stimulation. Heart attack. Deep brain stimulation and resulting seizure. And then Jasmine notices, a sharp—even for this client—escalation in trauma—motorcycle accident. Lumbar puncture for MS screening (At least *someone* had already done some rule-out screening ). Insulin shock.

Jasmine wonders again about suicidality—was there some life stressor so huge that it could have prompted both suicidality and a psychotic break? Jasmine knows almost instantly than she will put in for both an MRI—to rule-out brain tumors and visible brain damage—and also a rule-out on substance-related hallucinations. Maybe some additional neuro testing as well to rule neurological syndromes—such as complex, partial seizures—that can mimic psychosis, but beyond that, she's a bit scared to be honest. Clinical diagnosis is never easy, but she gets the sense that this will be especially hard.

Jasmine scans the rest of chart. He's a doctor, age 49, single, with one parent deceased. Referral and intake paperwork was completed by two emergency proxies that the client had had on file beforehand, "in the event of loss of competency, emergency, or loss of ability to communicate." Their names are Dr. James Wilson and Dr. Lisa Cuddy. Dr. Cuddy, Jasmine notes with interest, is the administrator of the hospital where Drs. House and Wilson work. Who makes their supervisor their medical proxy? Dr. Wilson, she's guessing, is a colleague, perhaps even a friend. That gives Jasmine the slightest glimmer of hope. At least he seems to know someone. The chief complaint reads, "Patient reported visual and auditory hallucinations two days ago, but came in this morning claiming that he had both detoxed from Vicodin and engaged in sexual intercourse with the hospital administrator. Both claims are contradicted by other evidence. According to his medical proxies, he appeared to "break down" in the hospital administrators office and requested voluntary admission to Mayfield."

_The hospital administrator? He hallucinated intercourse with the hospital administrator? The one who is also his medical proxy? _Jasmine is just a bit shell-shocked—not because what Gregory House reported had been particularly bizarre but because it wasn't. Because it seemed ever-so slightly tinged with a tiny bit of strange reality. Putting the file back, Jasmine is mystified as she walks into the therapy room where Dr. House is waiting.

"Dr. House? I'm Jasmine Miller, and I'm here to help us get a better picture of what's been happening in your life lately"

House's head snaps toward her. He doesn't look dishelved or disorganized, Jasmine's notes, but he looks beat—like he's been kicked straight to ground, straight to rock-bottom.

"I'm hallucinating. I want ECT." He states, almost rolling his eyes at her. The statement shocks her—no word salad and insight to boot. This isn't run of the mill schizophrenia. Even in the world of psychosis, some things are "normal." This isn't?

" So, you know when you're hallucinating and when you're not?" Jasmine asks surprised. Insight isn't normal in psychosis. Neither, for that matter, is asking for ECT.

Jasmine catches just the tiniest glimpse of fear in the man's striking eyes and then it's gone.

"I know I see dead people. I know that isn't exactly common. I also know they're _dead_. And I know you don't know bullshit. If you were a doctor, you would have said so. What are you? Some social worker who got tired of throwing drunks into a paddy wagon? Maybe a counselor with a two-year degree? A psychiatrist wannabe who failed out of Ochem? I told you, I'm hallucinating. I need ECT. Not someone who's going to ask if I ever _really_ wanted to bone mommy."

Jasmine uses all her willpower to keep her face blank and her voice flat. While it isn't customary to defend yourself to clients, she's getting the impression that motivational interviewing may not work all too well with this one.

"I'm a pre-doctoral intern. I've spent the last 9 years of my life researching, diagnosing, and treating psychosis. I've published 11 randomized, controlled trials on the best ways to do just that. I've read almost all of the literature in field. I may not be a doctor yet, but I can tell you ECT is no longer used to treat paranoid schizophrenia-type symptoms. It never was effective for those symptoms. Neither, for that matter, was Freudian theory. So, unless you show symptoms that ECT is indicated for, you're not going to get that. And I'm not a Freudian—if you want to discuss Oepidal feelings, feel free to bring them up, but I won't. You came here for treatment, Dr. House. I'm a treatment provider. If you choose not to work with me, that's your right, but failure to diagnose will hinder treatment."

For a second, he looks ready to fight her back, but then, he stops and glares at the corner—at something she cannot see—with fury.

"She came back," he says, the sound of defeat echoing in his voice.

"She?"

"Amber. The dead one. The hallucination."

"How longer have you been seeing her?"

"A few days. After my fellow killed himself. Thought she was a sleep-induced hallucination. She isn't."

Jasmine makes a note to go back to suicide later, writing "trigger" on her notepad.

"Is she the only person you believe you're hallucinating?"

"I thought so. But then I hallucinated a naked, horny Cuddy. And Kutner."

"Kutner?" she asks,

"The diagnostic fellow who blew his brains out," he says, in a strange tone—a mixture of bitterness, sarcasm, and, just perhaps, a bit of sadness.

"And you were always aware that these manifestations were hallucinations? That they weren't really present?"

"Amber. And Kutner."

"And Dr. Cuddy?"

"I thought she was real," he says, his whole face dropping.

"What made you realize that it was a hallucination?"

"It didn't add up. There was no logic. And the lipstick was really pills."

"Pills?"

"Vicodin."

"Do you believe you abuse, are dependent on, or misuse Vicodin?" she asks, a line she stole directly from her substance abuse treatment class. Her mind is still trying to catch up. Logic? Someone who actively looks for _logic_ during psychosis?

"I'm in fucking pain! I have half of a thigh muscle. I'm cripple! I _need_ Vicodin to function."

"Have you ever considered detoxing?" she asks calmly, not reacting, just like she's been trained.

"I cheat. We always cheat."

"We?"

"Amber and I."

"Does she ever tell you to hurt yourself or anyone else?"

House goes silent and looks like he's just been punched in head and heart simultaneously.

"No," he says, but the lie is obvious. Huge red flags shoot up, blazing, screaming. Jasmine doesn't think anyone ever gets used to treating a homicidal or suicidal client—or at least she won't. _Oh shit, _she thinks, _shit, shit, shit_. Contrary to popular belief, command hallucinations, especially homicidal and suicidal ones, are extremely rare. But they can happen.

"Dr. House, I need you to be very clear and honest. Have you or Amber ever hurt or wanted to hurt you or anyone else."

"I am her. She's my subconscious. She's dangerous. I don't trust her."

"Has she ever suggested you--"

"Yes!" House interrupts, furious. "That's why I want to fucking get rid of her. She's brilliant and dangerous."

"And you are, too?"

"I'm a diagnostician. I try to save lives. She tries to _kill _them."

"How?"

"By being me. By suggesting things."

"What kind of things?"

" Giving antibiotics that cause dermatological necrosis. Finding a stripper whose body butter the groom-to-be is allergic to."

"Why does she do this? Does she say?"

"Other people are happy."

"And you're not?"

"I don't give a shit! I want to solve cases, not delude myself with sun and rainbows, and _cute wittle puppy dogs_."

"But she does. And you said you're her."

"She's a part of me that needs to be controlled, and that can't happen when I'm fucking insane."

Freudian though she's not, but Jasmine can't help but think of the id.

"Are you planning to hurt someone now?"

"No."

"Are you planning to kill yourself now?"

"No."

"Have you ever tried to kill yourself?"

"Not for real."

"For real?"

"For good. "Never coming back" good. No."

She leaves that for another day, but checks first.

"Do you want to hurt yourself now?"

"No."

_Good,_ she thinks, _at least it could be worse._

"Have you ever hallucinated or had delusions prior to this?"

"Not while I was conscious."

"Have you ever been diagnosed with a psychological disorder before?"

"No."

"Have you ever seen a psychiatrist?"

He pauses and gets that same lonely, punched in hurt look.

"Once," he says, sounding as close to meek as Jasmine can imagine him being.

"Why?"

"It didn't work."

"Why did you go?"

"I don't know."

"What do you mean?"

"It didn't work."

"On what?"

"Anything. Me. Nothing changed."

"What were you expecting to change?"

"I don't know. Alone."

Jasmine would like to dig deeper, but she hears a knock on the heavy, reinforced door. The hour is up.

She pulls a question out of thin air, one that she usually would have asked at the very beginning of an assessment, not at the very end.

"Who would you call your friends?" she asks, excepting—even though she's been taught not to do that—an answer close to none.

"Wilson," House answers, and in that tiny split second before the attendants come in, she swears she sees him smile just a little bit.

As she writes up the case—her "nutshell" diagnosis reads "brief psychotic disorder with co-morbid substance dependence, r/o brain tumor and substance-induced psychosis. Reported being "alone."—she remembers something she saw in House's folder, on the medical proxy form—permission to release full medical and mental health records release to James Wilson. It had been signed, dated, and notarized two months before. Long before the fellow had committed suicide. House had known something was going wrong, and he wanted Wilson to have full access to everything. House didn't seem to trust anyone, but he must have trusted Wilson. House had said he was alone. Then why did he reach out to Wilson without telling him?

Jasmine doesn't usually believe in "deeper stories"—with schizophrenic clients, you typically don't get a lot of deep soul searching—but as she leaves the room, with diagnosis and rule-out suggestions in hand, all she can wonder is "why?"


End file.
